00000nam a22000004a 4500 UP-8027390931316428026 Buklod 20251001111128.0 m |o d | ta 250925s2025 xxu r |||| u|eng d PHARM rda eng LG 993.5 2025 P5 D33 Dacasin, Jared D. author Characterization and analysis of pediatric medication errors in a tertiary government hospital pharmacy through participatory action research model using Lean Six Sigma methodology. Jared D. Dacasin ; Jean Flor C. Casauay, adviser. Department of Pharmacy, College of Pharmacy, University of the Philippines Manila 2025 x, 151 leaves 28 cm. Thesis (Bachelor of Science in Pharmacy)--University of the Philippines Manila, February 2025 available to general public Medication errors are untoward events experienced by patients due to the inappropriate use of medications. Given the complex systems existing within tertiary government hospitals, pediatric patients are at higher risk of having medication errors. Several methods have been developed to address pediatric medication errors, however these methods lacked sustainability. Lean Six Sigma methodology has been studied to address medication errors based on the quality management and continuous improvement principles, however its effectiveness in dealing with pediatric medication errors is yet to be proven. Hence, this study aims to initiate a quality improvement program through the use of Lean Six Sigma methodology tools in a participatory action research model to facilitate the reduction of medication error occurrence. The Define-Measure-Analyze phase of the DMAIC methodology was conducted to understand the nuances of the pediatric medication error occurrence, to determine the extent of the errors, and to identify the root causes and ultimately propose possible solutions prior to full implementation. In the Define phase, the stakeholder analysis through the SIPOC diagrams showed that all different stakeholders in the drug management cycle influence the process of pediatric medication use in the hospital pharmacy. Furthermore, the understanding of the working system and process variables through the conduct of small discussion group produced several themes, which all showed that the medication dispensing process is not optimized yet to understand the appropriate attention that pediatric patients need in terms of therapeutic requirements, despite the best knowledge and efforts that the pharmacists have and do to maintain the medication dispensing system compliant to rules and safe from errors. In the Measure phase, a total of 85 pediatric patient health records were reviewed, with 186 medication errors detected in electronic health records and 48 errors in drug order system records. It was found that the pediatric medication errors were significantly reduced from an average of 63.3 in 2017 to 2.25 errors per chart in 2024 (a = 0.05). The use of salbutamol, amikacin, and ceftazidime were noted to be top contributors of medication errors which were the same medications that incurred the top errors as found in a previous study. The Analyze phase provided the synthesis that the validation steps of the process needed to be strengthened. Such analysis resulted in prioritizing incomplete orders, which resulted in five true root causes. To address these, the pharmacists and researcher formulated several recommendations, such as enhanced double checking of medication orders, access to pediatric patient health records, updating references and training on the importance of complete medication orders, and compliance to antimicrobial stewardship policies. From this experience, the principles of Lean Six Sigma were successfully integrated in a participatory action research model to investigate the factors of pediatric medication error occurrence. The conduct of the Define-Measure-Analyze phases under this model was able to derive logical and pragmatic solutions that will help in gearing towards a mindset change of all key stakeholders. The addition of extensive problem inquiry through small discussion group and thematic analysis in the Define phase and the thorough patient history checking in the Measure phase helped in better understanding the nuances of pediatric medication errors. Through this methodology, the pharmacists are empowered to lead towards the implementation of quality improvement measures to ensure prevention and eventual elimination of pediatric medication errors. Medication errors Prevention Pediatric pharmacology Philippines. Hospital pharmacies Quality control Six Sigma (Quality control standard). Action research in health care Participatory methods Philippines. Casauay, Jean Flor C. adviser. FI UP UPMNL PHARM LG 993.5 2025 P5 D33 Thesis